DOEA Form 234 "Application for Designation of a Home Health Agency as a Teaching Agency for Home and Community-Based Care" - Florida

Form 234 or the "Application For Designation Of A Home Health Agency As A Teaching Agency For Home And Community-based Care" is a form issued by the Florida Department of Elder Affairs.

The form was last revised in July 1, 2011 and is available for digital filing. Download an up-to-date Form 234 in PDF-format down below or look it up on the Florida Department of Elder Affairs Forms website.

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Download DOEA Form 234 "Application for Designation of a Home Health Agency as a Teaching Agency for Home and Community-Based Care" - Florida

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Department of
Application for Designation of a home
Elder Affairs
health Agency as a teaching Agency for
home and Community-based Care
state of flor ida
Section 430.81, F.S., allows the Department of Elder Affairs to designate a home health agency licensed under Chapter 400, Part III, F.S.,
that has access to a resident population of sufficient size to support education, training, and research relating to geriatric care as a teaching
agency for home and community-based care if the home health agency meets specific criteria as outlined in the statute.
Please respond to the following regarding the home health agency applying. Attach documentation as necessary.
1. AgEnCy nAmE
2. AgEnCy PhonE numbEr
3. AgEnCy ADDrESS
4. PrimAry Agency contAct
nAmE
EmAIl
PhonE numbEr
5. AgEnCy lICEnSE numbEr (ChAPtEr 400, PArt III, F.S.):
6. FlorIDA mEDICAID or mEDICArE CErtIFIED ProvIDEr
numbEr (IF APPlICAblE):
7. has this agency been a not-for-profit, designated community care for the elderly lead agency for home and community-based services
for more than 10 years?
(Please Check One)
yes
no
8. has this agency been in business in this state for a minimum of 20 consecutive years?
(Please Check One)
yes
If yes, please attach Florida Department of State Division of Corporations documentation.
no
9. Does this agency hold a valid accreditation from a nationally recognized accreditation program?
(Please Check One)
yes
If yes, please attach appropriate documentation of the accreditation.
no
10. Please attach a description and other documentation that demonstrates the agency’s active program in multidisciplinary education and
research that relates to gerontology.
11. Please attach a copy of a formalized affiliation agreement with at least one established academic research university with a nationally
accredited health professions program in this state.
12. Please attach a list of the salaried academic faculty from a nationally accredited health professions program employed by the agency.
Page 1 of 2
DOEA Form 234, July 2011
Section 430.81, F.S.
Department of
Application for Designation of a home
Elder Affairs
health Agency as a teaching Agency for
home and Community-based Care
state of flor ida
Section 430.81, F.S., allows the Department of Elder Affairs to designate a home health agency licensed under Chapter 400, Part III, F.S.,
that has access to a resident population of sufficient size to support education, training, and research relating to geriatric care as a teaching
agency for home and community-based care if the home health agency meets specific criteria as outlined in the statute.
Please respond to the following regarding the home health agency applying. Attach documentation as necessary.
1. AgEnCy nAmE
2. AgEnCy PhonE numbEr
3. AgEnCy ADDrESS
4. PrimAry Agency contAct
nAmE
EmAIl
PhonE numbEr
5. AgEnCy lICEnSE numbEr (ChAPtEr 400, PArt III, F.S.):
6. FlorIDA mEDICAID or mEDICArE CErtIFIED ProvIDEr
numbEr (IF APPlICAblE):
7. has this agency been a not-for-profit, designated community care for the elderly lead agency for home and community-based services
for more than 10 years?
(Please Check One)
yes
no
8. has this agency been in business in this state for a minimum of 20 consecutive years?
(Please Check One)
yes
If yes, please attach Florida Department of State Division of Corporations documentation.
no
9. Does this agency hold a valid accreditation from a nationally recognized accreditation program?
(Please Check One)
yes
If yes, please attach appropriate documentation of the accreditation.
no
10. Please attach a description and other documentation that demonstrates the agency’s active program in multidisciplinary education and
research that relates to gerontology.
11. Please attach a copy of a formalized affiliation agreement with at least one established academic research university with a nationally
accredited health professions program in this state.
12. Please attach a list of the salaried academic faculty from a nationally accredited health professions program employed by the agency.
Page 1 of 2
DOEA Form 234, July 2011
Section 430.81, F.S.
Department of
Elder Affairs
13. has this agency been a medicare and medicaid certified home health agency that has participated in the nursing home Diversion
Program for a minimum of five consecutive years?
(Please Check One)
yes
If yes, please attach a list of the Nursing Home Diversion providers and dates of affiliation which demonstrates five consecutive
years of provider affiliation.
no
14. Does this agency have proof of insurance coverage pursuant to Section 400.141(1)(s) F.S.?
(Please Check One)
yes
If yes, please attach verifying documentation.
no
If no, please respond to #15 below.
15. Proof of financial responsibility (only complete if response to #14 is “No”)
maintains an escrow account consisting of cash or assets eligible for deposit in accordance with Section 625.52 F.S.
Please provide verifying documentation.
or
obtains and maintains, pursuant to Chapter 675, F.S., an unexpired, irrevocable, nontransferable, and non-assignable letter of
credit issued by any bank or savings association authorized to do business in this state. This letter of credit shall be used to satisfy the
obligation of the agency to the claimant upon presentation of a final judgment indicating liability and awarding damages to be paid
by the facility or upon presentment of a settlement agreement signed by all parties to the agreement when such final judgment or
settlement is a result of a liability claim against the agency.
Please provide verifying documentation.
AdditionAl informAtion:
A teaching agency for home and community-based care may be affiliated with an academic health center in this state. The purpose of such
affiliation is to foster the development of methods for improving and expanding the capability of home health agencies to respond to the
medical health care, psychological, and social needs of frail and elderly persons by providing the most effective and appropriate services.
A teaching agency for home and community-based care shall serve as a resource for research and for training health care professionals
in providing health care services in home and community-based settings to frail and elderly persons. If your agency is affiliated with
an academic health center in this state, please attach a complete description of this affiliation. (Please note: This description is not a
requirement for designation.)
This form and the supporting documentation should be returned to:
florida department of elder Affairs
Attn: Jenny Rojas
4040 esplanade Way, Suite 335P
tallahassee, florida 32399-7000
Page 2 of 2
DOEA Form 234, July 2011
Section 430.81, F.S.
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